COMMUNITY JOB CONNECTION REGISTRATION FORM

Date 

Enter Today's Date

New ITCDC Client From Web Form

Record Type

ITCDC Record

Client ID

Please enter the last 4 of your SS# and first and last initials. (example 1234FL)

First Name

Last Name

Address

City

State

Zip

Select Your Neighborhood

Please select... Adair Park Ashview Heights Atlanta University Center Bankhead Capital City Gateway Castleberry Hill English Avenue Grove Park Mechanicsville Non-Atlanta Resident Other Atlanta Community (not listed) Peoplestown Pittsburgh Vine City Washington Park

Home Phone

Secondary Phone

Preferred Phone

Please select... Home Secondary Phone

Birthdate

Year of Birth

enter all 4 digits - 1964

Race

Please select... Black - African American White Hispanic Latino Asian American Indian Other

Gender

Please select... Male Female

Email

Preferred Email

Please select... Personal

Do You Use Social Media?

YesNo

Social Media Do You Use

Please select... Facebook Instagram Linked In Twitter

Which Services Are You Seeking?

Please select... Direct Employment Financial Counseling Home Ownership Readiness Services Job Fair Registration Lawncare Re-Entry Ex-offender Services Resume Assistance Senior Services Social Services Referrals Vocational Training Voter Registration Westside NET Job Readiness Program

Lead Source

Please select... Web Form

How Did You Hear About US?

Please select... AARP Atlanta Public Schools Atlanta Workforce Development Agency CEFGA City of Refuge Community Job Connection Bus Department of Community Supervision Facebook Faith Based/Church Organization Flier Instagram Integrity CDC Internet Probation/Parole Officer Quest Shelter/Transitional Housing Social Media Social Service/Government Agency TV/Radio Twitter Walk-In Word of Mouth YMCA

Event Name

Profile Data

Profile Date 

Enter Today's Date

Client ID (again)

Profile Record Type

ITCDC Profile Record

First Name

Last Name

Are you a Veteran

Yes

ITCDC Program

Please select... BEAUTIFICATION BRIDGE/ RE-ENTRY Community Job Connection (Direct Employment) DIGITAL LITERACY GED/ LITERACY ITCDC CARES Westside NET Forklift Certification Construction C NA / PCT CDL (Class A)

Are you currently employed

Yes

What is your current rate of pay?

How long have you been unemployed?

Please select... 0-6 months 1-2 years 3-4 years 5 years or longer 7-12 months

What was your previous rate of pay?

Receiving any Assistance

Yesunemployment, Food Stamps, etc...

Type of assistance you are receiving

Please select... Aging Services Child Care Child Support Services Disability Energy Assistance Food Stamps Housing Assistance Medicaid Medicare Mental Health Other Peachcare for Kids SSI Substance Abuse Services TANF Unemployment Insurance WIC Hold control key to select more than one answer

Do you have any Mental or Physical Disabilities

Yes

Please Explain Disability

Do you have reliable transportation?

Yes

Explain transportation problems

Do you have a Resume

Yes

Upload You Resume

Identification Section

Valid GA ID

Yes

Valid GA Driver's License

Yes

Drivers License Type

Please select... Regular (car) CDL (trucks) Other

Education

Education Level (s)

Please select... No High School Diploma or GED High School Grad GED Associate Degree Bachelor Degree Graduate Degree Technical College Hold control key to select more than one answer

Degree Type

Please select... AS BS Technical MA PhD OtherHold control key to select more than one answer

Would you like to enter a GED program

Yes

Would you like to receive training

Yes

Training you would you like to receive

Please select... Administrative/Clerical Certified Forklift Operator Child Development Associate Commercial Driver's License (Class A and B) Construction Electricians Facility Maintenance and Security Film Production Financial Services Food Service Food Services HVAC Information Technology Medical Warehouse/Logistics WeldingDo not select more than 3 choices. (hold control key to select more than one choice)

Employment and Skills

Previous Positions Held

Please select... Administrative/Clerical Certified Nursing Assistant Child Care Computers Construction Custodial/Janitorial Food Service Hotel Hospitality or Cleaning Landscaping Medical Assistant Other Patient Care Technician Restaurant/Fast Food Industry Retail Warehouse/Logistics (hold control key to select more than one choice)

Position Seeking

Please select... Administrative/Clerical Child Development Computers Construction Custodial/Janitorial Food Service Hotel Hospitality or Cleaning Landscaping Other Restaurant/Fast Food Industry Retail Warehouse/Logistics Certified Nursing Assistant Patient Care Technician Medical Assistant(hold control key to select more than one choice)

Barriers finding employment

Yes

What are your barriers finding employment

Please select... Child or elderly care Criminal History Lack of educational credential Long-term unemployed No valid GA ID or GA Driver's License Transportation(hold control key to select more than one choice)

Have you used drugs in the last 30 days

Yes

Are drugs an issue with you

Yes

Would you like drug treatment info

Yes

Will drugs hinder you from employment

Yes

 Do you have a Criminal History?  (This will not disqualify you for services, it will aid us in placement assistant).

YesNo

Have you been convicted of a felony

Yes

If yes – when

Do you need Legal Assistance

Yes

Referred By

Name or agency that referred you to this program?

Referral's Phone Number

Offense Type

Please select... Drugs related offenses Violent offenses Theft related offenses Sexual related offenses Other

Number of Misdemeanor Convictions

Please select... 1 2 3 4+

Date of most recent Misdemeanor 

Number of Felony Convictions

Please select... 1 2 3 4+

Date of most recent Felony 

Are you currently on probation?

Yes

Are you bonded?

Yes

Probation’s/ Parole Officer Name

Please explain your probation

Do you rent or own your home?

Are you interested in Home Ownership?

Yes